SOUTHEAST MISSOURI STATE UNIVERSITY

THIRD PARTY SEXUAL ASSAULT INCIDENT REPORT

Purpose:  This form is intended to 1) provide communication, 2) assist with further investigation, and 3) use the information gathered for the development of proactive sexual assault prevention programs.  All efforts must be made to maintain the victim’s anonymity; no information should be included which might identify the victim.  For more information contact the Dean of Students, Office of Student Development, University Center Room 422 (phone 651-2135).

Reporter’s name Phone
Status Date of Report
Email Date of  Discussion with Victim
Victim's Age Gender
Rank: Date of Incident
Time of Incident Occurred on Campus
If the assault occurred on campus, indicate where
Describe location (name of building , street, etc)  
Describe Assault (choose one)  
Sexual Contact (fondling, kissing, petting, but not penetration) without consent
Attempted intercourse without consent (penetration did not occur)
Intercourse (oral, anal or vaginal penetration by penis or other object) without consent
Unknown - blackout or no memory
Other (describe):
Was the absence of consent due to the victim being incapacitated by:  
  Alcohol  
  Other Drugs  
Describe the kind of pressure or force used by the assailant
None
Verbal pressure or arguments
Position of authority (boss, teacher, supervisor, etc)
Threat of physical force (threatened to hit, hold or otherwise injure)
Actually used physical force (hit, held victim down, twisted arm, etc)
Gave victim alcohol or other drugs so victim was significantly incapacitated
Was a weapon involved in the assault?  
If a weapon was involved, what kind?
Number of assailants    
Give physical description of the assailant(s)
For Assailant
For Second Assailant (if applicable)
For Third Assailant (if applicable)
Role of assailant(s) on campus    
If non-campus role, please describe:
Describe the nature of relationship with the assailant(s) prior to the incident
For Assailant  
For Second Assailant (if applicable)
For Third Assailant (if applicable)
Name of alleged assailant(s)
For Assailant
For Second Assailant (if applicable)
For Third Assailant (if applicable)
Other department(s) or agencies assault was reported to:
Residence Life Dean of Students University Counseling Services
University Police City Police  
Other